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Date of receipt:Ill health Retirement Medical Information Form Please complete this form using black ink and in BLOCK CAPITALS. Part A: To be completed by the applicant or their representative in

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Part a needs to be filled out by individuals who are applying for a specific program or benefit, as indicated in the instructions.

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The exact requirements for who needs to fill out part a will depend on the specific form and purpose, so it's important to carefully read the instructions before proceeding.

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